تمرکز توجه در مقابل حواس پرتی در طول مواجهه با ترس از دندانپزشکی
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|38724||2007||13 صفحه PDF||سفارش دهید||محاسبه نشده|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Behaviour Research and Therapy, Volume 45, Issue 11, November 2007, Pages 2691–2703
Abstract A survey of the discrepant findings regarding the effects of attention focusing and distraction on exposure suggested that subjective measures of anxiety and avoidance respond better to the latter condition, and heart rate (HR) reaction responds to the former. To test this hypothesis, 63 dental phobics were recruited who had not visited a dentist for a mean of 6.6 (1.5–25) years. Participants received a 1-h exposure session with either attention focusing or distraction. Subjective anxiety and HR to phobia-related pictures were assessed before and after the treatment session and again after 1 week. Avoidance was recorded in terms of adherence to the dental treatment schedule in the following 6 months. Contrary to expectation, state anxiety showed a greater decrease in the attention focusing than the distraction condition after 1 week. Both treatment conditions were similarly effective with regard to HR and avoidance. HR habituated in both groups after exposure and 73% of followed-up patients adhered to the dental treatment schedule. Comparison of the present with previous results suggests that the differences between attentional conditions tend to be more pronounced during shorter exposure sessions than were employed in the present study.
Introduction Specific phobias are strong, irrational fear responses to situations or objects, and phobics typically react with flight or avoidance when confronted with the phobic stimulus. Prolonged exposure to the phobic stimulus has long been found to be the most effective treatment method of this disorder, but some questions remain as to the mode of exposure. Among the problems still to be resolved is that of the attentional focus during exposure treatment: Need phobics attend the phobia-related material or is its presence just as efficacious in reducing anxiety if phobics are distracted? In the original model of emotional processing by Foa and Kozak (1986), attention focusing is essential for fear reduction. According to this model, exposure activates the prototype of the fear reaction, which consists of a neuronal network that contains all aspects of stimulus properties, and emotional, physiological and behavioural fear responses including cognitive appraisal. This fear structure is stored in memory and recalled on exposure to any of its elements. Exposure introduces corrective, incompatible information leading to an uncoupling of the elements. According to this model, attention focusing, which promotes sensory encoding of the presented phobic stimuli, is necessary for the full activation of the fear structure. In contrast, distraction strategies prevent encoding of the relevant stimulus elements and inhibit activation of the fear structure and thereby also emotional processing. Incomplete emotional processing is thought to result in partial relapse, also termed return of fear (e.g. Sartory, Rachman, & Grey, 1982). Alternatively, Bandura's model (1983) of fear reduction stresses the importance of self-efficacy, i.e., the individual's conviction to be able to cope with a situation. Accordingly, it is the perceived lack of self-efficacy that induces fear during potentially aversive situations (Bandura, 1988). Behavioural mastery of fear-inducing situations is considered to enhance perceived self-efficacy. Coping strategies aimed at mastery have been found to be highly effective in combination with exposure and to improve self-efficacy (Jones & Menzies, 2000). According to this model, fear reduction results from enhancement of self-efficacy. Distraction from phobic stimuli would be considered a coping strategy as it allows the phobic individual to master the situation with less anxiety than would otherwise have been the case. The experience of being relatively free from anxiety in the presence of the phobic stimulus improves perceived self-efficacy and contributes to fear reduction. As shown in Table 1, results of the condition of attention focusing and distraction during exposure treatment are inconsistent. In a first such study in obsessive-compulsive patients (Grayson, Foa, & Steketee, 1982), one group was asked to attend to the anxiety-inducing material and the other group was also asked to pick it up while playing a video game with the therapist during the treatment session. Both groups showed a similar extent of reduction in subjective discomfort at the end of the session but the attention group evidenced a more marked reduction in heart rate (HR). The distraction group experienced return of fear at the following session, whereas the attention group's fear reduction remained stable across sessions. In a subsequent study, Grayson, Foa, and Steketee (1986) failed to replicate the follow-up result but confirmed the greater HR decrease in the attention condition. In contrast, the distraction condition led to more improvement with regard to subjective units of discomfort (SUD). Subsequent studies showed discrepant results. Measures of SUD appear to favour distraction (Craske, Street, Jayaraman, & Barlow, 1991; Johnstone & Page, 2004; Penfold & Page, 1999), although there are also exceptions (Mohlman & Zinbarg, 2000; Oliver & Page, 2003). HR, on the other hand, appears to respond better to an attention-focusing condition (Grayson, Foa, & Steketee (1982) and Grayson, Foa, & Steketee (1986); Johnstone & Page, 2004). There are, however, also a number of studies showing no effect on HR by either condition (Craske et al., 1991; Kamphuis & Telch, 2000; Mohlman & Zinbarg, 2000). The elusiveness of the effect on HR may be due to differences in the way assessments were carried out. In some studies, HR was recorded during exposure, in others during the behavioural avoidance test. Even so, results suggest a pattern whereby distraction appears to have a superior effect on SUDs and approach as well as on cognitive factors such as self-efficacy and internal locus of control, whereas attention focusing appears to lead to greater improvement in physiological reactions to phobia-related stimuli. Various components of the phobic reaction may underlie different processing modes and therefore also respond to different treatment conditions.
نتیجه گیری انگلیسی
Results Group comparisons The attention group was significantly older than the distraction group (F(1,61)=12.79, p<.01; η2=.17; Table 2). There was no significant group difference with regard to gender composition (χ2=.21, p=.12). Questionnaires: Group means and SDs of questionnaire data are displayed in Table 3. As questionnaire data tend to be highly inter-correlated, a principal component analysis was initially carried out to explore the factor structure with the aim of extracting factor scores. As shown in Table 4, the principal component analysis with a subsequent varimax rotation of the eight questionnaires resulted in two factors: (I) a generalized anxiety and mood factor and (II) a specific phobia factor. Factor scores were extracted and submitted to 2×2 (group×measurement occasion, MO) ANOVAS. Factor I showed a marginally significant group×MO interaction (F(1,56)=3.08, p<.09, η2=.05). There were no other significant group effects with regard to either factor. Individual variables were then submitted to ANOVA with a 2×2 design comparing groups by measurement occasion (pre-treatment, follow-up after 1 week). There was no main effect for the group with regard to any of the questionnaires. There was, however, a measurement occasion effect with regard to most variables showing improvement from before the treatment session to follow-up. (DAS: F(1,61)=41.03, p<.01, η2=.40; DCQ: F(1,60)=25.47, p<.01; η2=.30; IDCI (predicted): F(1,57)=13.56, p<.01; η2=.19; STAI trait: F(1,61)=5.16, p<.03; η2=.08; BDI: F(1,60)=17.97, p<.01, η2=.23; ASF: F(1,59)=5.41, p<.03; η2=.08). Additionally, there was a significant group×measurement occasion effect in case of STAI state (F(1,61)=6.34, p<.02, η2=.09). Simple comparison of means revealed a significant STAI state increase in the distraction group from before treatment to follow-up (t(30)=−2.91, p<.01) with no other effects being significant. There was also a marginally significant interaction effect with regard to the DCQ (F(1,60)=2.83, p<.10, η2=.05). Attention engendered marginally greater improvement than distraction at follow-up. Table 3. Group means and SDs of questionnaire data Variable Attention (N=32) Distraction (N=31) Sign. effects Age 39.03 (9.23) 30.84 (8.94) G Sex (m/f) 17/15 11/20 n.s. Dental anxiety (DAS) Pre 17.53 (1.90) 17.23 (2.50) MO FU 15.38 (3.06) 15.45 (3.17) DCQ Pre 21.06 (6.23) 21.53 (7.47) MO FU 16.06 (6.34) 19.03 (7.90) G×MO* IDCI (desired control) Pre 21.26 (2.67) 21.03 (3.17) n.s. FU 21.06 (2.59) 20.90 (4.20) IDCI (predicted control) Pre 7.50 (2.53) 7.97 (2.49) MO FU 9.27 (3.08) 8.76 (2.55) State anxiety (STAI) Pre 40.00 (10.19) 37.68 (7.57) G×MO FU 38.19 (9.54) 41.74 (8.15) Trait anxiety (STAI) Pre 38.81 (9.55) 40.42 (8.32) MO FU 36.78 (8.98) 39.71 (9.99) Depression (BDI) Pre 6.34 (5.18) 8.87 (9.02) MO FU 4.31 (5.54) 6.73 (6.27) ASF (self efficacy) Pre 3.85 (.34) 3.75 (.44) MO FU 3.93 (.37) 3.84 (.52) SUDs Pre 1 83.75 (12.12) 75.48 (18.04) MO Pre 2 80.63 (15.65) 74.84 (18.23) G×MO* Post 60.63 (18.83) 58.06 (23.72) FU 62.81 (22.18) 63.55 (23.88) Resting HR (bpm) Pre 81.80 (16.13) 81.91 (10.38) MO Post 72.85 (13.51) 73.46 (7.83) FU 74.96 (12.21) 74.58 (9.58) Avoidance (% attendance of subsequent dental treatment) 66.7 (N=26) 79.3 (N=29) n.s. Significant effects denote main effects for G (group), MO (measurement occasion) and G×MO interaction. (*indicates a marginally significant effect; FU—follow-up assessment 1 week after exposure). Table options Table 4. Principal component analysis with Varimax rotation and Kaiser normalization of questionnaire data Variables Component 1 2 Trait anxiety (STAI) .897 .133 ASF (self efficacy) −.832 .057 Depression (BDI) .805 .072 State anxiety (STAI) .777 .061 IDCI (predicted control) −.093 −.808 Dental anxiety (DAS) −.052 .718 DCQ .379 .708 IDCI (desired control) −.035 .522 Table options SUDs were submitted to ANOVA with a 2×4 design. There was no significant group nor interaction effect of group×occasion ( Table 3). SUDs decreased significantly in both groups (F(3,59)=28.69, p<.01, η2=.59). Individual comparison of means revealed a significant decrease from before to after the treatment session whereas the other comparisons were not significant. Transformation of the repeated measures into linear, quadratic and cubic trends confirmed the results of a significant decrease and yielded a marginally significant group×linear trend (F=2.83, p<.10, η2=.04), with the attention group showing a greater decrease in SUDs over measurement occasions. Fear ratings of dental instruments are shown in Fig. 1. Data were submitted to a 2×4×3 (group×instrument×measurement occasion) ANOVA design. There were no significant group differences, but some instruments were considered more fear-arousing than others (F(3,183)=18.02, p<.01, η2=.23). Individual comparisons revealed the drill to be more fear-arousing than any of the other instruments and the pliers and hypodermic needle to be more fear-arousing than the dental probe. Fear ratings decreased from before to after treatment (F(2,122)=26.23, p<.01, η2=.30) and with a different course (instruments×MO: F(6,366)=3.39, p<.01, η2=.05), with fear ratings to the drill, unlike to the probe, showing an increase between the end of the treatment session and follow-up. Fear ratings of dental instruments at the beginning and end of their 15-min ... Fig. 1. Fear ratings of dental instruments at the beginning and end of their 15-min exposure (pre–post) and at the follow-up assessment 1 week later. The drill elicited higher fear ratings than the other instruments and lead to greater return of fear than the dental probe at follow-up. Figure options Appraisal of pictures: Both valence and fear ratings of pictures were submitted to an ANOVA with a 2×2×2 (group×pre-treatment/FU×stimulus type) design. There were no significant main nor interaction effects with regard to group but main effects for measurement occasion (fear: F(1,61)=37.05, p<.01, η2=.38; valence: F(1.61)=14.35, p<01), stimulus type (fear: F(1,61)=691.65, p<.01, η2=.92; valence: F(1,61)=483.31, p<.01) and a significant interaction effect between stimulus type and measurement occasion (fear: F(1,61)=38.12, p<.01, η2=.38; valence: F(1,61)=33.90, p<.01). Valence and fear ratings decreased more to phobia-related than to neutral pictures from before treatment to follow-up ( Fig. 2). Subjective appraisal of pictures in terms of fear and valence before the ... Fig. 2. Subjective appraisal of pictures in terms of fear and valence before the exposure session and at follow-up. Phobia-related pictures were given higher ratings than neutral pictures and their ratings improved more at follow-up. Figure options HR: Resting HR ( Table 3) was submitted to ANOVA with a 2×3 (group×measurement occasion) design. There was no significant group difference but a measurement occasion effect (F(2,60)=39.04, p<.01, η2=.57). A significant quadratic trend confirmed that tonic HR decreased from before to after treatment and did not increase again at follow-up. Submitting the evoked HR responses to ANOVA with a design of 2×3×2×6 (group×measurement occasion×stimulus type×second) revealed no significant group differences. There was a significant seconds effect and a stimulus type×seconds interaction (F(5,305)=5.07, p<.01, η2=.08) indicating that HR increased more to phobia-related than neutral pictures. A significant measurement occasion×stimulus type effect (F(2,122)=13.00, p<.01, η2=.18) showed that HR responses to phobia-related pictures decreased over occasions and the significant quadratic effect of occasions×stimulus type (p<.01) confirmed that the decrease occurred from before to after the treatment session and remained stable at follow-up ( Fig. 3). HR reactions to phobia-related and neutral pictures before and after treatment ... Fig. 3. HR reactions to phobia-related and neutral pictures before and after treatment and at follow-up. HR accelerated more to the former than the latter stimuli and improved from before to after treatment. Figure options Avoidance: Attendance of dental treatment could not be assessed in 7 participants because records could not be traced (5 of the attention and 2 of the distraction group). Forty-one (73.2%) of the remaining 56 participants underwent and completed the subsequent dental treatment, 10 attended two and 2 one dental cleaning sessions before terminating dental treatment prematurely. Three participants stayed away altogether. There was no significant group difference with regard to avoidance (Mann–Whitney U=350.00, n.s., two-tailed). Relations between measures Age was only correlated with time since the last dental treatment (r=.30, p<.03). As indicated by the principal component analysis, questionnaire measures and ratings were highly inter-correlated. Avoidance was highly and positively correlated with STAI state (r=.47, p<.001) and trait anxiety (r=.41, p<.01) as well as with IDCI (desired control) (r=.39, p<.01) and BDI depression (r=.40, p<.01) as assessed at the first occasion. Neither resting HR nor HR responses were significantly correlated with any of the other measures.